Cardiology Consultation Update Letter

Dear Dr. Sarah Jenkins,

Thank you for referring Mr. Arthur Pendelton for assessment of new-onset exertional dyspnea and irregular pulse.

As you are aware, Mr. Arthur Pendelton is a 68-year-old male whose relevant medical background is outlined below:

Cardiac-Related History

• Essential hypertension (diagnosed 2015)
• Dyslipidemia

Other Past Medical History

• Type 2 diabetes mellitus (T2DM)
• Mild osteoarthritis of the knees
• Gastroesophageal reflux disease (GERD)

Cardiac Risk Factors

• Hypertension
• Dyslipidemia
• T2DM
• Ex-smoker (20 pack-year history, quit 2010)

Social History

Mr. Pendelton is a retired high school teacher who lives in a two-story home with his wife. He is independent with all activities of daily living. He quit smoking 14 years ago and consumes approximately 2 to 3 standard alcoholic drinks per week. He walks his dog daily for 20 minutes, though this has been recently limited by his symptoms.

Allergies And Intolerances

• Penicillin (maculopapular rash)
• Lisinopril (dry cough)

Current Cardiac Medicines

• Candesartan 16 mg PO daily
• Rosuvastatin (Crestor®) 20 mg PO daily

Other Relevant Current Medicines

• Metformin (Glucophage®) 1,000 mg PO BID
• Pantoprazole (Pantoloc®) 40 mg PO daily
• Paracetamol (acetaminophen, Tylenol®) 500 mg PO PRN

Family History

His father had a myocardial infarction at age 62. His mother had hypertension and died of a stroke at age 81. There is no family history of sudden cardiac death or premature arrhythmia.

Presenting Complaint And Illness History

Mr. Pendelton reports a 6-week history of progressive exertional dyspnea, classified as NYHA Class II. He notices shortness of breath when walking up moderate inclines or climbing a single flight of stairs, which resolves within 5 minutes of rest. He also describes intermittent episodes of rapid, irregular palpitations lasting several hours over the past month. He denies any chest pain, pressure, orthopnea, paroxysmal nocturnal dyspnea, presyncope, or syncope.

Review Of Systems

• Constitutional: No fever, chills, or unintentional weight loss.
• Respiratory: No chronic cough, wheezing, or hemoptysis.
• Gastrointestinal: No abdominal pain, nausea, or melena.
• Neurological: No focal weakness, numbness, or visual changes.

Physical Examination

On examination today at 10:30, the patient appears comfortable and in no acute distress. Heart rate is 88 bpm and irregularly irregular, blood pressure is 138/84 mmHg seated, respiratory rate is 16 breaths/min, oxygen saturation is 97 % on room air, and temperature is 36.7 °C. Weight is 84 kg and BMI is 27.4 kg/m². Jugular venous pressure is normal at 2 cm above the sternal angle. Carotid upstrokes are brisk and without bruits. Cardiac auscultation reveals a variable S1, normal S2, and no murmurs, rubs, or gallops. Chest auscultation is clear bilaterally with no crackles or wheezes. The abdomen is soft and non-tender without hepatosplenomegaly. There is trace pitting edema at the bilateral ankles, and peripheral pulses are intact.

Investigations

• 12-Lead ECG (14/05/2024): Atrial fibrillation with a ventricular rate of 86 bpm, normal axis, no acute ischemic ST-T wave changes, QTc 420 ms.
• Transthoracic Echocardiogram (10/05/2024): Normal left ventricular size and systolic function with an ejection fraction of 58 %. Mild left atrial enlargement (LAVI 36 mL/m²). Mild mitral regurgitation, structurally normal valves, no pericardial effusion.
• Labs (08/05/2024): Hemoglobin 142 g/L, platelets 210 x 10^9/L, creatinine 88 µmol/L, eGFR 74 mL/min/1.73m², potassium 4.3 mmol/L, TSH 2.1 mIU/L, HbA1c 6.8 %, LDL-C 1.8 mmol/L.

Assessment And Plan

For the clinical matters identified

1. New-Onset Atrial Fibrillation Mr. Pendelton presents with symptomatic atrial fibrillation and a controlled resting ventricular rate. Given his age and history of hypertension and diabetes, his CHA2DS2-VASc score is 3, warranting oral anticoagulation for stroke prevention. I have initiated apixaban (Eliquis®) 5 mg PO BID after discussing bleeding risks. To improve his exertional symptoms and control exercise-induced tachycardia, I have also started bisoprolol 2.5 mg PO daily. I have ordered a 48-hour Holter monitor to assess overall rate control and potential tachy-brady episodes.

2. Hypertension His blood pressure is reasonably controlled today at 138/84 mmHg, and the addition of bisoprolol should help achieve his target of less than 130/80 mmHg. He will continue candesartan 16 mg PO daily and monitor his blood pressure at home twice weekly.

3. Dyslipidemia and Type 2 Diabetes Mellitus His lipid profile and glycemic control are currently at target. He will continue rosuvastatin (Crestor®) 20 mg PO daily and metformin (Glucophage®) 1,000 mg PO BID without change.

Follow-Up

I will review Mr. Pendelton in my clinic in 3 months following completion of the 48-hour Holter monitor, or sooner if his symptoms worsen.

I have advised the patient to seek immediate medical attention at the nearest emergency department if he develops severe chest pain, resting shortness of breath, syncope, or signs of significant bleeding.

Thank you for your involvement in the care of Mr. Arthur Pendelton. Please contact me if you would like to discuss any aspect of the case.

Dictated on 14/05/2024 at 11:15 EST. Dr. Marcus Vance, MD, FRCPC Internal Medicine Specialist CPSO #84920, OHIP Billing #049281 cc: Dr. Sarah Jenkins (Family Physician)